Assessment & outcome measures

Elderly Rehabilitation

Rotational B5 PT Core IST

Why is good assessment important?

• Specific treatment planning

• Decision making – rehab goals

• MDT contribution – eg M&H, medical management

• Discharge planning

• Delegation

• Patient confidence

• Person centred

Subjective assessment

• HPC• PMH• DH• Social history• Falls history• Symptoms – pain, dizziness• Cognition – AMT4, AWI, or delirium? 4AT?• Consent• Patient’s perceptions and expectations

Objective Assessment (1)

• Observation• ROM• Strength• Quality of movement• Co-ordination – tremor, dysmetria,

bradykinesia• Tone – resistance, rigidity, cogwheeling• Proprioception• Sensation

Objective Assessment (2) - Function

• Bed TF’s and mobility

• Sitting balance

• STS

• Standing balance

• Gait

• Risk Assess for moving and handling

• I Can board

Problem lists

Don’t forget impairments as well as function – eg:• Low back pain • Reduced swallow• Kyphosis & decreased ROM neck & T/sp• Tight hams, adductors and gastroc/soleus• Weak quads and gluts• Reduced bed mobility – Ao2• Reduced STS – Ao1• Reduced standing balance – decreased fwd wt TF• Altered gait pattern – Ao1 with WWF

Making decisions(1) Does the patient have rehab goals?

Things to consider:• Cognitive function• Previous ability and input• Family/carer support• Degree of physiological changes• Medical causes of deterioration• Motivation• Underlying problem – can it be changed? eg

strength, length, or can it be compensated for eg with equip.

Goals

• Person centred

• SMART

• Short term and long term

• Discharge orientated

• Involvement of family / carers

• In agreement with MDT

Making decisions (2) How do we assess risk?

• What do we put on their I Can board?

• Move Goals

• Will they make it the distance to the toilet with the nurses?

• Could they walk with family members?

• Is the person safe to walk by themselves?

How do we assess risk?

• Risk vs consequences

• But what about real patients/people in real life situations?

• Do we weigh up with positives as well as the negatives?

• And do we consider their choice? (?capacity)

Consider:

Degree of risk of falls

• Insight/safety awareness

• Mobility

• Tinetti < 18?

• Vision

• Age

• Medical condition

Consequences of fall

• High fracture risk eg osteoporosis

• Potential for injury related to IV lines, catheter, O2 therapy etc

• Increased length of stay

• previous falls

Benefits of walking

• Maintain /improve strength and balance therefore may reduce falls risk

• Maintain / improve cardiovascular fitness

• Emotional wellbeing

• Improve quality of life

• Mental stimulation

What does the patient/person want?

Practicalities – how do we decide degree of risk?

• Tinetti balance – use it and prove it

• Functional reach – literally functional – can they open the toilet door? Can they reach their trousers? Can the let go to wash their hands

• Walk through their ADLs

• Is the WWF going to be left beside them or will others keep moving it out of the way?

Jimmy

• TL = WWF and AO1 on ward

• Tinetti 16 – poor gait but can stand narrow BOS and reach unaided

• NS think he’s taking risks ‘wandering’

• Jimmy’s desperate to get going!

• What do you do?

• What else do you want to know to help your decision?

Jimmy

• Is Jimmy distressed by not being allowed to walk independently?

• Does he have capacity?

• What do the family think?

• What do the MDT think?

• Do the benefits of walking (physical and emotional) outweigh the risk?

• I think Jimmy should go for it! ??

• But address risks…

• Footwear

• Ensure walking aid nearby

• Chair and bed at appropriate height

• Glasses / hearing aids in use

• Strength and balance programme

• I Can board

• Educate staff on benefits of walking and quality of life *active wards*

• Involve family /carers

• Check signage

• Monitor /treat pain

What about Jean?

• Persistently trying to get up indep

• Tinetti 10

• Can’t stand without support of WWF

• Delirium

• Poor vision despite glasses on

• Several falls on ward already

• Family putting in a complaint

Not safe to mobilise

independently

Assist Jean to walk on all occasions

she wishes (where possible)

Strategies to help:

•Address need (eg toilet, hunger, pain…)

•Involve family/carers to assist where

appropriate

• Consider falls alarm if not distressed by

it??

•Encourage MDT to walk with Jean

regularly especially if showing signs of

trying to get up

•Consider stimulation / Activity

Coordinators / Volunteers

•Encourage appropriate seating to

promote safety and independence

Take home message re risky decisions:

• People (with dementia) have the right… – “to maintain their best level of physical, mental, social and

emotional wellbeing”– “to be as independent as possible”

• Start with what the patient/person wants to do• Choose the least restrictive option• Balance the risk with the reward – think quality of

life (but be sensible and use your PT toolkit)

Outcome Measures

• Not only help our decision making…

• What else? • Evidence value of input

• Validated tools

• Reference point for problems

• Part could be used as an objective marker eg TUSS/6MTW –or even a treatment

• Marker of progression/regression

• Relevant across admissions

• Reference point of function – admission/discharge

Which outcome measure to choose?

• Appropriateness - is the content of the measure appropriate to the context of the intervention?

• Reliability - does the measure produce results that are reproducible and internally consistent?

• Validity - does the measure record what it claims to record?• Responsiveness - does the measure detect changes over

time that matter to the patient / team?• Interpretability - how interpretable are the scores – will it

pick up a clinically significant difference?• Acceptability - is the measure acceptable to the patient?• Feasibility - how easy is the measure to administer and

process?

Common Outcome Measures

• Elderly Mobility Score• Tinetti gait and balance score• Berg balance scale• ‘Get-up and go’ timed (not TUAG)

• Other potential OMs Elderly Rehab: 30s chair stand, FES-I (falls efficacy scale), Lindop, UPDRS, 6min walk, 2min walk

• Can’t use 4 test balance scale – but could use part as an objective marker? Eg TUSS, timed tandem stand, SLS

• www.quest.scot.nhs.uk (GG&C library network)

Group work…

• Look at each outcome measure

• Consider positives and negatives of each

• When would you use it?

• Have a go at carrying it out on each other

• How would you measure 6mTW, FR etc?

• Talk about common uncertainties – are we all doing the same thing?

EMS

Positives

• Validated

• Reliable

• Easy to use

• Useful for frail elderly

Note functional reach test:

Unwilling to reach – 28x more likely to fall

Reach less than 15cm - 4x more likely to fall

Negatives

• Lacks specificity

• Plateaus quickly

• Cannot measure change in people who are independent

SCORES:<10 = dependent

>14 = independent

Tinetti

Positives

• More comprehensive measure of balance and gait

• Reliable

• Valid

• Responsive to change

• Easy to use, no equip

• Predicts falls risk:– <18 high

– 19-23 moderate

– >24 low

Negatives

• Predicts falls risk but doesn’t take into account other factors such as cognition, vision etc

• Doesn’t measure reach

• Some lack of clarity between staff on 360 turn and other parts?

• Not as good for frailer pts

Berg

Positives

• Comprehensive measure of balance

• Good selection of functional real life activities

• Good for assessment and finding an objective marker

• Best for higher level patients such as day hospital, community

Negatives

• Doesn’t look at gait

• Most of our inpatients don’t get far through test – really need to be able to stand unsupported for 1 min

• Need some equipment

• Takes longer

• Scores: <23 high falls risk, >45 safe to be indep unaided